89-2396 - Laserfiche WebLink

Home Browse Search

APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL T ON AVE., STOCKTON, CA Telephone (209) 466-6781 `Z Ca ✓ PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described. This application is made in compliance with San Joaquin Counly Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. Job Address J L� .,..4 City Lot Size � PM Owner's Name _ Address • 0 c` � Phone' Contractor � -Address L /111/vnen License No.��d Phone y YE7 F6 TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications 11 Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout I I irrigation Approx. Depth I I Eastern Surface Seal Installed by - Repair Work Done ❑ Type of Pump H.P. State,Work Done _ Well Destruction ❑ Well Diameter Sealing Material (top 501 0 Depth Filler Material {below 50'I — Q TYPE OF SEPTIC WORK: NEW INSTALLATION I REPAIR/ADDITION l 1 DESTRUCTION i I (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence—P�— Commercial_ Other Number of living units: Number of bedrooms `� � f f� _ 0-Ala.r� �C�.� Water table depth Character of soil to a depth of 3 feet: 4 � SEPTIC TANK ❑ Type/Mfg , Capacity •+✓ No. Compartments PKG. TREATMENT PLT. ❑ Method of Disposal - Distance to nearest: Well Z7C� Foundation Property Line LEACHING LINE No. & Length of lines 3 Total length/size FILTER BED 1-1Distance to nearest: Well ,oU� Foundation' Property Line Z.W SEEPAGE PITS D4 Depth Size eI2� _ Number SUMPS Ll Distance to nearest: Well ZQ c3 Foundation Property Line DISPOSAL PONDS ❑ hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health Di§trict. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman's compensation laws of California."Contractor's hiring or sub-contracting signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall employ persons subject to workman's compensa- tion laws of Californi ' The applicant mu II for al .r a spections. Co plata drawing on reverse sic1q. g Signed X Title: Date: FOR DEPARTMENT USE ONLY Application Accepted by Date Z7, 7 � Area 1 / 4r Grout Inspection b U'�`f�ate& 2dLow` Final Inspectionn��'� Data J� Additional Comments: ,V C1 Stk 466-6781 ❑ Lodi 369-3621 ❑ Manteca 823-7104 ❑ Tracy 835-6385 Applicant - Return all copies to: Environmental Health Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEET DUE AMOUNT REMITTED GK RECEIVED 13Y DATE PERMIT- NO. INFO AMOUN CASH + EH 13-24(REV.r i N 5)EH 14-28 �-Z-3